Aviata At Coral Bay

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record and policy review, the facility failed to provide a well-balanced diet that meets nutritional needs and honors residents' preferences for 2 of 5 residents sampled for food preferences (Resident #16 and Resident #51). The findings included: The facility's policy titled Dining and Food Preferences which originated 05/2015 and revised and 10/2022 revealed The Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents/patients that do not consume certain foods or food groups. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. 1. Resident #51 was admitted to the facility on [DATE] with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide restorative therapy as recommended by the Director of Physical Therapy for 2 of 2 sampled residents (Resident #62, and Resident #104.) The findings included: 1. Review of the record revealed Resident #62 was initially admitted on [DATE] with the admitting diagnosis of Paraplegia (the inability to voluntarily move the lower parts of the body.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview on 04/07/25 at 10:23 AM, when asked if he received any kind of therapy, Resident #62 stated he wasn't sure what kind of therapy he received but was pretty sure it was called restorative therapy. When asked how often he received it, he stated it wasn't that often because they don't have a lot of staff available to provide it; but when he received it, it helped. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately document narcotic administration for 2 of 6 residents reviewed (Resident #79 and Resident #377). The findings included: 1. Review of the record revealed Resident #377 was admitted on [DATE] with a diagnosis of Encephalopathy (a condition where there is brain disease, damage or malfunction). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #377 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating the Resident had moderate cognitive impairment. Review of the current orders revealed Resident #377 had an active order for Lorazepam 0.5mg tablet one tablet by mouth every 8 hours as needed. 2. Review of the record revealed Resident #79 had an initial admission of 04/04/23 and re-entry on 08/15/24 with a primary diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side (a condition where there is paralysis and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a pneumococcal vaccination to a resident who consented to receive the pneumococcal immunization for 1 of 5 residents sampled for immunizations (Resident #32). The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses that included Dementia, Congestive Heart Failure, and Type 2 Diabetes Mellitus. His Brief Interview for Mental Status (BIMS) score was 2 on the quarterly minimum data set with an assessment reference date of 02/23/25. This indicated the resident had severe cognitive impairment. On 04/09/25 at 4:00 PM an interview was conducted with the Infection Preventionist and the Director of Nurses (DON). A record review was conducted of 5 residents for receiving flu and pneumonia vaccines. A consent to receive a pneumonia vaccine was signed on 09/05/24 for Resident #32. There was no record in the electronic health record (EHR) that this vaccine was administered. The DON and Infection Preventionist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical and administrative record review and interviews, the facility failed to ensure that the staff consistently implemented the system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications. Failed to ensure prompt identification of loss or potential diversion of controlled medications and the determination of the extent of loss or potential diversion of controlled medications for 3 of 3 residents (Residents #1, #2 and #3). The findings included: 1) Review of the clinical record for Resident # 1 physician prescriptions revealed that the physician prescribed on 08/08/24 Dilaudid Oral Tablet 8 mg (Hydromorphone HCL) Give 1 tablet by mouth every 8 hours as needed for pain per pain management, and Xtampza ER Oral Capsule ER 18 mg Give 1 capsule by mouth every 12 hours for pain. Review of the Medication Monitoring/Control Record and the corresponding Medication Administration Record (MAR) revealed that the nurses did not consistently document the administration of the Dilaudid/Hydromorphone tab 8 mg one tablet by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to provide evidence that allegations for abuse and neglect were thoroughly investigated. This is evidenced by the facility's failure to provide evidence conducting thorough investigations for 2 of 3 sampled residents (Residents #1 and #2). The findings included: Review of the facility's policy titled Abuse, Neglect, Exploitation & Misappropriation, Revision Date 11/16/22, documented regarding investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. A Social Service representative may be offered in the role of resident advocate during any questioning of or interviewing of residents. Investigations will be accomplished in the following manner. Preliminary Investigation: Immediately upon investigation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee shall perform and document a through nursing evaluation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical and administrative record review and interviews, the facility failed to consistently provide effective pain management by failing to obtain pain medication refills in a timely manner to ensure 1 of 3 residents reviewed (Resident #1), did not have extended periods of time without pain medications. The findings included: Review of the clinical record for Resident # 1 revealed that the resident was admitted to the facility on [DATE] with pertinent diagnoses which included: Intervertebral disc displacement lumbar region, pain in left foot, pain in right foot, low back pain, pain in joints of right hand, opioid dependence with other opioid-induced disorder, idiopathic peripheral autonomic neuropathy, peripheral vascular disease, and Diabetes Mellitus with Diabetic Neuropathy. Review of the physician prescriptions revealed that the physician prescribed on 08/08/24 Dilaudid Oral Tablet 8 mg (Hydromorphone HCL) Give 1 tablet by mouth every 8 hours as needed for pain per pain management; and Xtampza ER…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide supervision to prevent an elopement for 1 of 3 resident reviewed for elopement risk (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. Diagnoses included End Stage Renal Disease, Diabetes, Generalized Anxiety Disorder, and Unspecified Mood Disorder. A comprehensive assessment dated [DATE] documented Resident #1 was cognitively intact and required partial/moderate assistance with activities of daily living. The resident was assessed and care planned for at risk for elopement on 05/03/24. The resident had interventions in place. On 06/19/24 at 11:00 AM, Resident #1 exited the facility. The resident was returned to the facility at 12:30 PM by law enforcement. Facility investigation revealed Resident #1 exited the facility at approximately 5:00 AM on 06/19/24. Resident #1 was returned to the facility at 5:15 AM by staff. No additional interventions were put in place. An interview was conducted with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to honor choices for 3 of 7 sampled residents. The facility failed to provide the requested RSV (Respiratory Syncytial Virus) vaccine for Resident #22. The facility failed to provide showers as per resident request and facility schedule for Residents #23 and #24. The findings included: 1) During an interview on 12/11/23 at 12:59 PM, Resident #22 stated he had not received the RSV vaccine that he had requested months ago. When asked who he spoke with, the resident stated the Assistant Director of Nursing (ADON). When asked how she responded, Resident #22 stated someone told him either when it was available or when they have enough people for a batch. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to ensure a safe and comfortable environment for 2 of 2 sampled residents. Staff were aware of missing dentures for Resident #18 and their policy was not followed related to loss or theft. Resident #22 requested that his dripping bathroom faucet be fixed, and it was not completed timely. The findings included: 1) Review of the policy Personal Property - loss or theft revised 07/24/17 documented, Process: . 5. An employee receiving a concern regarding lost or missing item(s) from a resident or resident representative will initiate a Complaint/Grievance form or electronic equivalent. During an observation and interview on 12/11/23 at 3:10 PM, Resident #18 was noted with just her upper dentures, as her lower lip was obviously sunken into her mouth. When asked if she had her lower dentures, Resident #18 stated she did not and that she did not recall when she lost them. Review of a written complaint to the State Agency dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessments related to medications for 2 of 5 sampled residents (Resident #18 and #23), and for 1 of 3 sampled resident discharges (Resident #81). The findings included: 1) Review of the record revealed Resident #18 was admitted to the facility 12/18/20. Review of the current MDS assessment dated [DATE] documented Resident #18 received an insulin injection on 7 of 7 days during the look-back period of 10/17/23 through 10/23/23. Review of the corresponding Medication Administration Record (MAR) revealed Resident #18 was ordered Levemir insulin every night at bedtime. Further review revealed the resident did not receive any insulin on 10/20/23. During an interview on 12/14/23 at approximately 4:30 PM, the Regional Nurse Consultant agreed with the findings. 2) Review of the record revealed Resident #23 was admitted to the facility 04/20/18. Review of the current MDS dated [DATE] documented the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to develop a care plan for 4 of 23 sampled residents: a resident with an indwelling catheter (Resident #75), residents with oxygen (Resident #14 and #31), and a resident with a Peg tube (Resident #62); and implement a care plan for a resident with a Peg tube (Resident #62). The findings included: 1) Resident #62 was initially admitted to the facility on [DATE] with diagnoses that included post Cerebral Infarction, Dysphagia, and Aphasia. The admission assessment dated [DATE] revealed the resident was admitted with a Peg tube (Percutaneous Endoscopic Gastrostomy which is a tube that brings nutrition directly into the stomach). His admission weight dated 08/23/22 was 172 pounds and his feeding was Jevity 1.5 CAL @ 65ml (milliliters (ml) per hour (hr) x 20 hours. A Brief Interview of Mental Status (BIMS) was not able to be performed per the resident's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/23. This MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to coordinate hospice services for 1 of 1 sampled resident, after having been treated at the hospital (Resident #14). The findings included: Review of the record revealed Resident #14 was admitted to the facility on [DATE] with hospice services in place. As per the electronic medical record census report, Resident #14 was last readmitted to the facility on [DATE], after a short hospitalization, with the payor source documented as the hospice provider. Review of the current Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 was terminal and was receiving hospice services. The MDS overview then documented a discharge assessment was completed on 11/18/23 and an entry assessment was completed on 11/21/23. No other MDS was pending or in progress after 11/21/23. Review of the current orders, both in the electronic and paper records, lacked a current order for hospice services. Review of the progress notes since the readmission date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure proper care and services for 1 of 1 sampled resident who had an indwelling urinary catheter (Resident #75). The findings included: Review of the policy Urinary Catheter Care revised 09/05/17 documented, Procedure: . Remove catheter securement device while maintaining connection with drainage tube. Clean catheter tubing with soap and water, starting close to urinary meatus (opening), cleaning in circular motion along its length for about 4 inches, moving away from the body. Rinse well using the same motion. Reattach catheter securement device. Observations on 12/11/23 at 9:36 AM, 12/12/23 at 11:06 AM, and 12/13/23 at 4:14 PM revealed Resident #75 had a urinary drainage device, as the urine collection bag was noted hanging from an open drawer in the resident's nightstand. Observation of the urine in the tubing revealed it was cloudy (Photographic Evidence Obtained). Resident #75 lacked any type of anchoring device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure proper care and services for 3 of 3 sampled residents utilizing oxygen (Residents #14, #23, and #31). The findings included: Upon request of the policy related to oxygen maintenance and use, the Regional Clinical Director provided their Administration of Medication - Oral policy, revised 08/15/19, and stated oxygen is a medication, so should be administered as per physician order and this policy. When asked specifically about oxygen tubing changes, the Regional Clinical Director stated there should be a physician order to follow. 1) During an observation on 12/11/23 at 10:29 AM, Resident #14 was noted in bed. Next to her bed was a running oxygen concentrator, set at about 2 liters/minute, with the tubing running over to the nightstand, and the nasal canula lying directly on top of the nightstand (Photographic Evidence Obtained). The oxygen tubing lacked any date and there was no bag to properly store and document the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to identify and clarify a physician's order for a drug with no dosage strength during monthly drug regimen review for 1 out of 7 residents observed for medication pass observation (Resident #70). The findings included: Review of the facility's policy titled, Medication Regimen Review (MRR) with a revision date of 08/17/23 included the following: The Consultant Pharmacist will conduct MMRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the resident's health record. The facility and Consultant Pharmacist will follow guidance outlined in the CMS State Operations Manual Appendix PP and current practice guidelines, for the appropriate provision of pharmaceutical care. Record review for Resident #70 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and Other Sequelae Following Unspecified Cerebrovascular Disease.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure appropriate behavior monitoring for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #18). The findings included: Observations on 12/11/23 and 12/12/23 throughout the day revealed Resident #18 sporadically yelling out. The resident would have intervals of loudly yelling out, sometimes heard through a closed door. At other times the resident would be quiet and appeared content. Review of the record revealed Resident #18 was originally admitted to the facility on [DATE], with a current readmission on [DATE]. Review of the current orders revealed Resident #18 was on Xanax for anxiety, and Olanzapine for a bipolar disorder. Review of the current orders and record lacked any monitoring for behaviors. Further review of the record revealed in October 2023, Resident #18 exhibited behaviors of agitation, calling out, or screaming on 5 of 93 shifts. Interventions for behaviors, to include one-to-one attention, position…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to serve food in a sanitary manner. The findings included: On 12/11/23 at 7:37AM, an initial tour was conducted of the main kitchen with the Certified Dietary Manager. The following was observed: (1) A test of the red bucket revealed that the solution was 150 ppm instead of 200-400 ppm. (2) A fire extinguisher was hanging from the ceiling over a stainless-steel table, the bottom of the extinguisher is rusted. (3) The ceiling tiles in the kitchen are broken and there is black dust all over it. (4) The stove and the oven are dirty with grease and burnt on food. (5) The plate lowerator that clean plates are placed, is dirty with stains of food. On 12/11/23 at 12:20 PM, an interview was conducted with the Certified Dietary Manager to review the findings. She acknowledged the findings. On 12/14/23 at 11:20 AM, a tour of the facility nourishment pantries was conducted with the Certified Dietary Manager. The first-floor pantry had a leak in the ceiling coming from the second-floor pantry refrigerator that is located right above it.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) for 2 of 2 sampled residents observed receiving high contact resident care activities (Residents #75 and #62). The facility had 20 current residents on Enhanced Barrier Precautions at the time of the survey. The findings included: Review of the policy Enhanced Barrier Precautions dated 09/01/22 documented, Policy: Enhanced barrier precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high contact resident care activities. Definitions: Indwelling medical device - includes but is not limited to central lines, urinary catheter, feeding tube, tracheostomy, and ventilator. High contact care activity - provide opportunities for transfer of MDRO to staff hands and clothing. High contact care activities include: . device care or use, such as . urinary catheter, feeding tube, . 1) During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide the pneumococcal vaccine for 1 of 1 sampled resident, as requested by Resident #22. The findings included: During an interview on 12/11/23 12:59 PM, Resident #22 stated he had requested to receive the most current pneumonia (pneumococcal) vaccine at the facility months ago. When asked who he spoke with, Resident #22 named the Assistant Director of Nursing (ADON). Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating he was cognitively intact. Review of the most current comprehensive MDS assessment dated [DATE], documented it was very important for Resident #22 to be involved in all his daily preferences. Review of the record lacked any evidence for the provision of the pneumococcal vaccine. During an interview on 12/13/23 at 12:51 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide meals that were prepared and served in a sanitary manner and in a manner to prevent the formation of pathogens that cause foodborne illness. The findings included: 1). During the initial kitchen tour, accompanied by Staff A, Cook, Staff A stated that the Dietary Manager was on vacation and would not be at the facility during the survey and stated that she was the designated person in charge of the kitchen in the absence of the Dietary Manager. The following were noted: a. There was an accumulation of residue on the blade of the can opener. b. The unit that mounted the can opener was noted to be encrusted with food residue. c. There was an accumulation of residue inside of the kettle used for making batches of tea. d. There was an accumulation of debris underneath the tea machine. e. The portion scale was noted to have what appeared to be rust on the platform of the scale as well as the body of the scale. f. Numerous cutting boards…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act on a change in condition in a timely manner for 3 of 3 residents reviewed for hospitalizations (Residents #8, #52, and #89). The findings included: A review of the facility's policy and procedure on Notification of Change in Condition, revised 09/21/17, documented: The nurse to notify the attending physician and resident Representative when there is a significant change in the patient. The nurse to complete an evaluation of the patient/resident. Document the evaluation in the medical records. Licensed Practical Nurse (LPN) will notify the Registered Nurse (RN) on shift with a suspected change of condition of a resident observed by that LPN, to complete an assessment. The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. If the Medical Director does not respond, call 911 and document in the medical record. 1. Resident #8 was admitted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the facility in a clean, comfortable and home like environment on 1 of 2 units (200 unit). The findings included: An environmental tour was conducted on 08/17/22 at 11:30 AM with the Plant Operations Director and House Keeping Manager. The following was observed: 1. room [ROOM NUMBER] had missing slates on window blinds, bathroom light fixture with debris and insect carcasses, and air conditioner unit with dust and debris. 2. room [ROOM NUMBER] air conditioner unit with dust and debris, bathroom floor border separating. 3. room [ROOM NUMBER] air conditioner unit with dust and debris, paint on wall peeling, bathroom floor border separating, and bathroom paint peeling. 4. room [ROOM NUMBER] air conditioner unit with dust and debris, bathroom floor tiles loose. room [ROOM NUMBER] air conditioner unit with dust and debris, walls with nails and stains. The Plant Operations Director and House Keeping Manager acknowledged the above.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide ADL (Activities of Daily Living) Care in the form of shower per resident's preference and according to determined schedule for 1 of 4 residents reviewed for ADLs, (Resident #42). The findings included: Resident #42 was admitted to the facility for current stay on 10/19/20. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #42 had a Brief Interview for Mental Status (BIMS) score of 8, indicating 'moderately impaired'. The MDS documented that Resident #42 required Extensive to limited assistance and 'one person physical assist' for Activities of Daily Living (ADLs) with the exception of eating and locomotion on unit. The assessment documented that Resident #42 required 'Physical help in part of bathing activity' with 'One person physical assist' and that the resident was ambulatory with the use of a walker and/or a wheelchair. The assessment documented that Resident #42 was 'always incontinent' of urine and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide restorative services to 4 of 4 residents reviewed for Restorative care (Residents #59, #20, #79, and #21). The findings included: A review of the facility's policy Restorative Nursing Services, revised 08/24/17, documented: Restorative Nursing will be provided to residents as indicated upon evaluation to assist in achieving the highest practicable level of physical functioning as possible. Therapy may refer a resident to restorative upon discharge from therapy services as deemed appropriate. Restorative programs provided by Restorative Nursing Assistants will be documented each time the program is provided on the Restorative Tracking Form. A weekly restorative nursing assistant note will also be completed weekly on the progress of the program on the restorative Tracking Form. Restorative programming will be included in the resident written plan of care. 1.) Resident #59 was admitted to the facility on [DATE] with multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to provide services to accurately monitor weight, feed resident and prevent weight loss for 1 of 3 residents reviewed for nutrition, (Resident #65). The findings included: On 08/15/22 at 12:43 PM, Resident #65 was observed resting in bed with eyes closed. A family member at the bedside said he feeds the resident when he is there. On the same day, preliminary record review showed Resident #65 was admitted to the facility on [DATE] after a stroke. Additional diagnoses included Dementia, Diabetes, Anemia, and Protein-Calorie Malnutrition. The resident's height and weight were documented as 66 tall and 117 pounds on 07/06/22, the day prior to admission. The admission progress note identified +2 (moderate) pitting edema to her arms and +3 (severe) pitting edema to both legs caused by fluid retention. Review of the comprehensive assessments completed on 07/18/22 and 08/11/22 showed BIMS (Brief Interview for Mental Status) exam scores…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, policy review and record review, the facility failed to maintain accurate documentation of regular maintenance, compatibility, and areas of entrapment for 3 of 3 residents observed for use of bed rails (Residents #12, #30 and #244). The findings included: On 08/15/22 at 9:24 AM, Resident #12 was noted to have bilateral side rails in the raised position for use on the bed. The side rails were tall, rectangular metal half-rails with multiple gaps between the bars, large enough for a limb to be trapped. On 08/15/22 at 10:37 AM, Resident #244 was observed in bed, with the same half-rails as described above in the raised position for use on the bed. While demonstrating continuous full body movements, the resident was also tightly gripping the right siderail with both hands pulling it toward him. Resident #244 has advanced Parkinsons with Dementia, as well as vision and hearing deficits. On 08/15/22 at 12:06 PM, Resident #30 was noted to have side rails on the bed in the raised position for use, however the rails were one-quarter to one-third the length of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.